Florida Clean Air Act (FCAA) Complaint Form

Contact Information

Name:

Email Address:

Phone Number:

In the event your complaint is shared with the Bureau of Tobacco Free Florida, would you like to remain anonymous to property management and/or governing board?
 Yes
 No

Type of Complaint

Please indicate the nature of exposure. (Select all that apply)
 Tobacco/Nicotine Smoke
 Tobacco/Nicotine Vapor/Aerosol
 Marijuana Smoke
 Marijuana Vapor/Aerosol
 Other – Please specify: 

Where is smoking/vaping occurring?
 Workplace/Business
 Multiunit Housing
        (e.g., condominium, apartment, duplex, townhouse, assisted living facility)
 Restaurant, Bar, or Bar Lounge
 Public Space
        (e.g., public beach, public park, etc.)
 Other – Please specify: 

Please provide the location of the complaint.
Property/Building Name

Street Address

County

Zip Code

Name of the property/building contact if known
(e.g., property manager, owner, board member, etc.) *optional

Email and/or phone number of the property/building contact if known
(e.g., property manager, owner, board member, etc.) *optional

Additional Information

Does the location, where smoking/vaping is occurring, currently prohibit the use of tobacco products?
 Yes
 No
 Unknown

Are people smoking indoors?
 Yes – Where? 
 No
 Unknown

Are people smoking outdoors?
 Yes – Where? 
 No
 Unknown

Please provide any additional details you would like to provide to the FCAA Consultant at the Florida Department of Health: